Qmentum Accreditation

What is Accreditation Canada's Qmentum Program?

Most hospitals and inpatient facilities in Canada participate in accreditation using the Accreditation Canada Qmentum Program. The Qmentum Accreditation Program is designed to focus on quality and safety throughout all aspects of an organization’s services—from governance and leadership to direct care and infrastructure—to benefit patients, clients, residents, staff and volunteers. Following a site visit, an organization may be awarded an accreditation designation of “accredited”, “accredited with commendation”, or “accredited with exemplary status” for the next four years.

Qmentum provides a wide variety of service excellence standards that describe best practices at the point of care in a multitude of different services, settings and populations. The standards are kept current thanks to regular revisions through national consultation with field experts. The latest versions of the standards, which will apply to site visits starting in 2015, were released in January 2014.

To assess quality and compliance with the standards, Accreditation Canada surveyors observe day to day processes through a number of tracers. For example, in an Episode of Care tracer, surveyors follow the path of a patient through its interactions with a particular team or service, from first point of contact to end of service. The tracer is an opportunity for the surveyor to view services through the eyes of the patients, focusing on their experience with transitions of care, effective information transfer, continuity of care, efficient flow, and patient/family involvement.

The Acute and Rehabilitation SCI Standards of Care, developed through a partnership between the RHI and Accreditation Canada, are an example of service excellence standards that are part of the Qmentum Program. The intent of the standards was to provide content that is tailored to reflect the unique needs and journeys of care of persons with SCI and to incorporate current evidence-informed best practice in SCI care. This specialized content will help centres better pinpoint where to focus their efforts to advance practice, with an added richness when compared to the more generic service standards.

Learn more about the Acute and Rehab SCI Standards.

Measuring improvement

The reporting of indicators has not traditionally been a part of the Qmentum accreditation program: at this time it is not required to submit indicator data to Accreditation Canada to be accredited under Qmentum. However, centres do need to successfully demonstrate that they have robust processes around measuring for improvement.

This content has been significantly strengthened in the latest version of service excellence standards released in January 2014. Therefore, for site visits starting in 2015, the criteria language now requires organizations to provide more specific detail around how they select meaningful indicators of both process and outcome, how they are measured over time, how they benchmark against peers, and more importantly, how they use the data to drive improvement.

A nationally coordinated strategy for common key performance indicators would not only help each centre to demonstrate compliance with the standards around measurement for improvement, but it would also represent a Leading Practice (a Leading Practice is an innovative example of leadership and service delivery that has been recognized by Accreditation Canada). This will establish the SCI community of care as leaders and innovators amongst other program areas that have not yet developed this level of robustness for measuring improvement.

How is this related to the National Action Plan?

During the ACT workshop, the Accreditation Canada Trauma Distinction Program indicators were proposed for measuring the SCI system of care (pre-hospital through to the community) as part of the ACT data collection process in the National Action Plan. Collection of indicators could help facilities meet the requirements for successfully demonstrating that facilities have robust processes around measuring for improvement (see above).